Migraine acute treatment

Posted On February 14, 2020

Acute migraine treatment options

Emergency Setting

  • Sumatriptan 6 mg sq
  • Metoclopramide 10 mg iv
  • Dihydroergotaimne (DHE 45) 1 mg iv
  • Ketorolac 30 mg iv or 60 mg im
  • Dexamethasone: 10-25 mg iv or im to reduce early recurrence

NSAID

  • Ketorolac: 30 mg iv or 60 mg im
  • Indomethacin 50 mg suppository
  • Naproxen 750 mg to 1250 mg po
  • Pregnancy: chronic use may be associated with infertility. Avoid use in pregnancy.

Triptans – serotonin agonist, do not use > 10 days/month

  • Sumatriptan (Imitrex)
    • po: 50-100 mg, may repeat after 2 hours, max 200 mg/24 hr
    • sq: 3-6 mg, may repeat after 1 hour, max 12 mg/24 hour
    • Intranasal spray: 20 mg spray, may repeat after 2 hours, max 40 mg/24 hours
    • Sumatriptan exposure in first trimester: major birth defects 4.2% based on Manufacturer registry, registry has now closed. Swedish medical birth register , no increased major congenital malformation observed.
  • Eletriptan (Relpax): available 24-40 mg tab
    • 20-40 mg po, may repeat in 2 hours, max 80 mg/day

Antimetic

  • Metoclopramide: 10 mg iv
    • Pregnancy: no report of increased risk.
  • Chloropromazine: 10 mg iv or im.
    • Pregnancy: jaundice, extrpyramidal symptoms have been reported in newborn.

Dihydroergotamine (DHE45): alpha adrenergic blocker

  • Pregnancy: oxytocic and should not be used during pregnancy.
  • iv: 0.5 mg q8, if tolerates 1 mg iv q8
  • nasal spray DHE mesylate (Migtranal): 4mg spray. 8 vials of spray cost over $1500

CGRP antagonists: mediate trigeminovascular pain transmission

  • Ubrogepant (Ubrelvy) 50-100 mg po
    • may repeat once after 2 hours, max 200 mg per 24 hour
    • Pregnancy: animal reproduction studies: may cause fetal harm
  • Lasmiditan (Reyvow) 50, 100, 200 mg.
    • no more than 1 dose per 24 hours
    • Do not operate heavy machinery or drive for 8 hours
    • Main side effect dizziness
    • Pregnancy: Adverse events were observed in animal reproduction studies.

Migraine in pregnant patient

  • Acetaminophen 650-1000 mg and Metoclopramide 10 mg
  • Acetaminophen and codeine 30 mg, limit to < 8 days per month
  • Bultabital-acetaminophen-caffeine (fioricet), should be limited to 4-5 days per month
  • Triptan:
    • sumatriptan: manufacturer’s registry did not show increased risk of birth defect or early pregnancy loss
      • 50-100 mg po or
      • 4 to 6 mg sq or
      • 5-20 mg intrnasal
    • Rizatriptan
  • Opiods: potentially addictive, may cause nervous system malformation
  • For nausea
    • metoclopramide 10 mg iv
    • Promethazine 12.5 to 25 mg po, per rectum or IM
    • Ondansetrom (Zofran) 2-8 mg po or iv
  • Refractory migraine:
    • Droperidol 2.5 mg iv q 30 min up to 3 doses
    • Magnesium Sulfate 1 or 2 gram iv over 15 minutes
  • DO NOT use ergotamine, isometheptene